Lower GIT Bleeding
Lower GIT Bleeding
Lower GIT Bleeding
Prepared by:
ABDULLAH AL-QAHTANI AHMED AL-BAHARNA
2031040016 2031040004
Supervised by:
Prof. Lade Wosornu
Definition
In chronic cases:
Patients present with the passage of bright red blood per rectum as blood on the tissue
paper or on the outside of formed stool in the absence of other symptoms.
General physical examination is normal.
In some cases, abdominal pain may be the chief complaint but it is not always a reliable sign
b/c:
It does not necessarily imply that there is bleeding (low specificity).
It does not accurately localize the site of the bleeding.
Symptoms
Acute gastrointestinal bleeding first will appear as vomiting of blood, bloody bowel
movements, or black, tarry stools. Blood may look like "coffee grounds." Symptoms
associated with blood loss can include the following:
Fatigue
Weakness
Shortness of breath
Abdominal pain
Pale appearance
Vomiting of blood usually originates from an upper GI source. Bright red or maroon
stool can be from either a lower GI source or from brisk bleeding at an upper GI
source.
Long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black stools,
or a positive test for microscopic blood.
Signs
Blood per rectum occurs with any GI source.
Hematochezia (seen in 80% of all GI Bleeding):
Grossly bloody, maroon or dark red stool.
Usually correlates with lower GI bleeding.
Brisk upper GI bleeding may cause (11%).
Melena (Black tarry stool):
Black tarry stool requires 150 to 200 cc blood.
Black non-tarry stool requires 60 cc blood.
Blood must be in GI tract 8 hours to turn black.
Stool remains black for several days in GI tract.
Melana source:
Present in 70% of upper GI bleeding
Present in 33% of lower GI bleeding
Blood in toilet (e.g. Hemorrhoids source):
Toilet water may appear bright red from 5 cc blood
Differential Diagnosis
1- non-infective causes :
Diverticular Disease.
Angiodysplasia
Haemorrhoids .
Anal Fissure ( especially in children ) .
Rectal Prolapse .
Neoplasms of the anal canal and orifices , rectum , large
intestine .
Benign Malignant
Adenocarcinoma
Polyps Squamous Carcinoma
Melanoma
2- infective causes :
Enteric Fever (salmonella)
Bilharziasis
Amebiasis
Diverticular disease (40%)
•Most Common Cause of lower GI bleeding.
•Symtoms:
Severe Lt. iliac fossa pain, nausea, loss
of appetite and constipation.
Angiodysplasia (30%)
Angiodysplasia is vascular
malformation associated with
ageing.consist of dilated
tortuuous submucosal veins
•Symptoms:
•Watery or bloody diarrhea (1st)
•Rectal discharge: bloody or
purulent.
•Proctitis (25%)
•Left sided colitis (15%)
•Total colitis (25%)
•Early pain is unusual.
•Relapses and remission (chronic)
Polyps
INITIAL INVESTIGATIONS
• General:
1. CBC
2. PT & PPT
3. Blood group & cross matching
4. Stool studies
• Specific:
1. Rectal examination:
• Inspection: discharge, ulceration, protruding masses, fissure, prolapse.
• Rectal digital examination: tone of sphincter, normal structures,…..etc
• Rectoscopy
2. Endoscopy: diagnostic and therapeutic procedure.
Proctoscope
Endoscopy
3. Barium enema
4. Angiography:
• It detects bleeding in GIT when it exceeds 1 – 2 ml/min.
• It is indicated when the site of Bleeding has not been detected by
endoscope.
• It is a diagnostic and therapeutic
(embolization of bleeding vessels )
procedure.
5. colonoscopy
6. Sigmoidoscopy
7. Radionucleotide scanning :
Valuable and very sensitive to
detect slower bleeding (0.5 ml/min),
usually a complementary technique
to angiography.
less invasive and more sensitive
than angiography.
But less accurate than angiography
in localizing the site of bleeding.
•As a conclusion to investigations:
“for patients without contraindications to
endoscopy, colonoscopy, or both, are preferred
as first-line procedures over angiography and
radionucleotide scanning. Patients who cannot
be stabilized by these procedures should
undergo surgery to localize
and
control bleeding”
TREATMENT
A. Initial treatment:
ABC management (Resuscitation)
• Airways
• Breathing
• Circulation
Assessment of hemodynamic stability.
Assessment of severity of bleeding.
TREATMENT cont.
B. Medical treatment (after stabilization)
C. Surgical treatment (according to cause of
bleeding):
Operation is limited to segmental colonic
resection if the bleeding site has been
localized conclusively.
Total abdomenal colectomy with iliorectal
anastomosis is only for persistent colonic
bleeding of unknown origin.
Postoperateive Complications
A. Immediate (1st 24 hours):-
Urinary retention: Inadequate fluid replacement
intra and postoperatively.
Primary hemorrhage: Starting during surgery
Replace blood loss and return to theatre if
necessary
Reactive hemorrhage: Bleeding following
postoperatively increase in blood pressure
Replace blood loss and re-explore wound.
Shock Blood loss, MI, Pulmonary Embolism or
Septicemia.
Postoperateive Complications cont.
B. Early (1st weak):-
Nausea and vomiting: Analgesia or anesthetic related;
paralytic ileus
Secondary Hemorrhage: Often as a result of infection
DVT
Acute Urinary Retention
Urinary Tract Infection
Postoperative Wound Infection
Bowel Obstruction: due to fibrinous adhesions
Paralytic ileus
Postoperateive Complications cont.